Medicare Advantage is an optional private health insurance counterpart to Original Medicare, which is funded and administered by the US government. It is commonly called MA or Medicare Part C, compared to Original Medicare Part A, which covers hospital insurance, and Part B, which covers outpatient care. Parts A and B extend the same coverage to all beneficiaries, but Medicare Advantage offers different tiers and costs of coverage. MA also covers hearing, vision, prescription drugs and wellness programs—options not provided under Original Medicare. People who enroll in Medicare Advantage do not need Medigap, a supplemental policy only available with Original Medicare.
About 39% of all Medicare beneficiaries are enrolled in a Medicare Advantage plan across the country. However, individual states have shares of beneficiaries varying from less than 10% to over 41%. At 41%, Rhode Island has a slightly higher rate than the national average. Connecticut to the west is even higher at 44%, while Massachusetts, Rhode Island’s northern neighbor, has a significantly lower share at 24%.
Rhode Islanders considering Medicare Advantage can choose among dozens of HMO, PPO, SNP or MSA plans. Not all options are offered in every county. This guide takes you through these types of plans as well as prescription drug coverage for Rhode Island enrollees and enrollment periods for Medicare Advantage. We’ve also listed various state and local agencies that provide Medicare resources and counseling to help seniors choose a suitable Medicare Advantage plan.
In Rhode Island, seniors may participate in one of four plan types: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs) and Medical Savings Accounts (MSAs). They vary in freedom to choose physicians, cost and options for prescription drug coverage. It’s important to find out if the plan you’re interested in is offered in your area.
Health Maintenance Organizations (HMOs)
HMO plans are typically more economical than other types of MA coverage, but the tradeoff is less flexibility in using your benefits. Under these plans, you must use health care providers and hospitals within your designated network. Otherwise, you may likely have to pay the entire bill out of pocket. The only exception is for emergency room visits. Most HMOs require you to select a primary care physician and get a referral from them to see any specialist.
In Rhode Island, some HMO plans include prescription drug coverage. Also, some let older individuals use services outside of the plan’s network for a higher copayment or coinsurance. These plans are called HMO Point-of-Service (HMO-POS) plans.
Preferred Provider Organizations (PPOs)
PPO plans give you a little more freedom than HMOs, offering limited coverage for care received outside of the PPO network. While you can see any doctor or specialist, you’ll pay the lowest possible copays and coinsurance if you stay in your designated network of providers. You would not need a referral, either. PPO plans are typically more expensive than HMOs.
Special Needs Plans (SNPs)
SNPs provide customized insurance benefits to individuals with low income, disabilities, or certain health issues. To qualify, a person must have the condition that the SNP addresses. These plans require members to select a primary care doctor who will give referrals as needed, although some plans may offer limited out-of-network coverage. The law mandates that SNP provide coverage for prescription drugs, while HMOs and PPOs are not required to.
Medical Savings Accounts (MSAs)
Similar to health savings account plans, MSAs blend a high-deductible health insurance plan and a medical savings account for paying medical expenses up to the plan’s deductible. These plans allow enrollees to choose their healthcare providers and services. MSAs do not offer Medicare prescription drug coverage.
Prior to enrolling in Medicare Advantage, seniors must first be enrolled in Original Medicare. Anyone who is eligible for Medicare Parts A and B is also eligible to enroll in Medicare Advantage. However, certain Medicare Advantage plans, such as SNPs, may have additional eligibility requirements.
Medicare Advantage has specific enrollment periods. One can only join a Medicare Advantage plan during the following periods:
Additionally, Medicare Advantage plan participants can change their plan outside of these enrollment periods under certain qualifying circumstances, such as moving to a new state.
Medicare Advantage plans known as MA-PDs have a prescription medication component that helps cover the cost of approved drugs. The monthly premium may include an amount for prescription overage, but many of these plans have $0 premiums. If you want your premium deducted from your Social Security or Railroad Retirement Board payment, contact the drug plan for guidance.
PDPs are stand-alone prescription drug or Medicare Part D plans that help subsidize medication expenses. These plans are suitable for seniors with an MSA plan which does not have drug coverage. However, people in an HMO or PPO cannot join a separate PDP or they will be removed from Medicare Advantage and placed back into traditional Medicare. Not all PDP plans are available in every part of the state.
Rhode Islanders who qualify could get help paying for medicines through the Rhode Island Pharmaceutical Assistance to Elders (RIPAE) program. This provision defrays a portion of the costs of approved medications purchased during the deductible state of a Medicare Part D plan. RIPAE has four levels: Levels 1-3 are for adults ages 65 and older, and level 4 is designed for adults aged 55-64 who are living with disabilities. Contact the Office of Healthy Aging at 401-462-0560 for more information or find the RIPAE application here.
Getting Medicare Advantage and understanding its intricacies can be quite challenging. The plethora of options and stipulations can make it difficult to decide what type of Medicare plan is the best choice. Below, we’ve outlined some free state and community resources in Rhode Island that can point you in the right direction for choosing your Medicare Advantage plan.
Rhode Island’s Executive Office of Health and Human Services (EOHHS) serves the state’s seniors through various agencies to help seniors maintain dignity and independence with Medicare counseling, food assistance, adult day services and protective supports. It also provides assistance with long-term-care issues. The EOHHS oversees the Senior Health Insurance Program (SHIP) discussed below.
For information and assistance, call the EOHHS Main Phone Line at 401-462-5274.
Rhode Island’s Senior Health Insurance Program (SHIP) offers seniors and their families free education and counseling to help them make informed choices regarding Medicare coverage. This service is designed to clarify costs and enable beneficiaries to get the most out of their benefits.
SHIP representatives at the state office can be reached by phone at 401-462-0510, and local counselors are available at locations listed below.
The Office of Healthy Aging, formerly known as the Division of Elderly Affairs, collaborates with organizations all over the state to connect seniors with resources and information, including healthcare information, and advocate for the rights and comforts of the elderly. It manages a Healthy Aging Help Desk where seniors and caregivers can report elder abuse, financial exploitation and neglect via a secure web portal.
The OHA oversees the Point, a network of services and programs for older residents. There are six regional Point offices throughout Rhode Island with specialists available to connect seniors to local resources for free. These services are available to individuals aged 55 and older, adults living with a disability, or their caregivers. Case Managers provide guidance with health insurance, medical assistance, elder abuse prevention and nutrition services. These trained professionals share important information about local, state and federal programs to enhance well-being and self-sufficiency.
Call the Point’s Central Office at 401-462-4444 for details regarding services, or call 2-1-1. You can also reach out to your nearby regional Point office listed below.Region 1 Office: Tri-County Community Action Agency – Northern RegionServing North Providence, Johnston, North Smithfield, Smithfield, Burrillville and Gloucester Phone: 401-351-2750Region 2 Office: West Bay Community Action PartnershipServing Warwick, West Warwick and East GreenwichPhone: 401-732-4660Email: [email protected]. A web contact form is available here as well.Region 3 Office: Tri-County South Community Action Agency – Southern RegionServing Charlestown, Exeter, Hopkinton, Narragansett, New Shoreham, North Kingstown, South Kingstown, Richmond, West Greenwich, WesterlyPhone: 401-789-3016Region 4 Office: United Way of Rhode IslandServing the entire statePhone: 401-519-0360Region 5 Office: East Bay Community Action Program – Upper Bay RegionServing Barrington, Bristol, East Providence and WarrenPhone: 401-437-1000, ext. 156Region 6 Office: Child and Family Services of Newport CountyServing Newport CountyPhone: 401-849-2300Visit Website Email
Warwick Senior Services in Warwick provides SHIP counseling for the community’s older residents by appointment only. The staff screens interested seniors to determine eligibility for Medicare Advantage and other programs using monthly income. The center also offers a legal clinic, tax help and assistance with subsidized housing and heating expenses. It publishes a newsletter to keep local seniors up to date on activities such as workshops.
Call Warwick Senior Services at 401-468-4070 or 401-468-4090 for information or assistance.
Senior Services, Inc., is a nonprofit offering a broad range of services for seniors and people with disabilities in northern Rhode Island. As a partner in the state’s Point network, this organization has a Community Information Specialist who shares free information on eligibility for programs, including Medicare Advantage, throughout the state. Its radio program The Senior Scene and public-access television show The Prime of Life are popular area resources for learning about benefits, services and deadlines.
To schedule an appointment with the Community Information Specialist, call 401-766-3734.
The West Warwick Senior and Community Center offers the town’s older residents SHIP options, counseling and pharmaceutical assistance in addition to meals, financial education and social activities.
Call the West Warwick Senior and Community Center at 401-822-4450 to set an appointment with a SHIP counselor.
The Office of Veterans Services can assist Rhode Island veterans with Medicare information. Veteran Affairs benefits include prescription drug coverage which is not affected by enrollment in a Medicare Advantage plan or Medicare Part D plan.
Call the state Office of Veterans Services at 401-921-2119 for eligibility information and assistance.